Efficacy of a Social Determinants of Health Training Intervention

BACKGROUND Social determinants of health (SDOH) are circumstances, such as living and work conditions, that affect patient health outcomes and contribute to health inequalities. Understanding patients’ SDOH can help physicians recognize barriers to care. Therefore, it is important that medical students learn to gather information on SDOH from patients. METHODS Standardized patient (SP) encounters with rising third-year students were analyzed to determine if an educational intervention about SDOH increased the frequency SDOH were discussed with patients. SP encounters were randomly sampled from 2017 (pre-intervention, n1 = 37) and 2018 (post-intervention, n2 = 40) video recordings of students eliciting a new patient history in a primary care setting. Discussions regarding SDOH categories were coded by question type (yes/no versus open-ended) and the language used by the student. RESULTS The post-intervention cohort more frequently discussed all SDOH topics during their encounters except discrimination (0% for both years). However, housing, mental health, and employment were the only SDOH categories discussed more than 50% of the time for either cohort. On average, students in the post-intervention cohort asked more open-ended questions rather than yes/no questions when discussing SDOH. Open-ended questions allowed patients to give more details and sparked further conversation than yes/no questions. DISCUSSION The SDOH training intervention increased the frequency that most SDOH were discussed in patient encounters, but these data suggest there are still opportunities for more students to routinely elicit this information from patients. SDOH and open-ended questioning skills can be emphasized in medical education to help address health inequalities.https://ir.library.louisville.edu/uars/1060/thumbnail.jp

Screening for E-cigarette and Tobacco Use in Standardized Patient Encounters

E-cigarette usage has grown significantly in recent years, with over 5 million US middle and high school students reporting recent usage. The long-term health consequences of these devices are still being investigated, but it is known that e-cigarette aerosol could contain harmful substances including nicotine, heavy metals, and carcinogens. Therefore, it is important for physicians to ask patients about e-cigarette usage specifically, as this may contribute to future health problems. The goal of this study was to investigate if and how medical students screen for e-cigarette usage. Screening language was reviewed in standardized patient encounters, which are a type of assessment that medical students undergo in order to observe how they interact with simulated patients. Video-taped patient encounters were coded to examine the specific phrasing of questions related to tobacco usage, including initial and follow-up questions. The majority of students (97%) did not ask about e-cigarettes specifically. Most students (66%) simply asked, “Do you smoke?” Overall, the evidence shows that e-cigarette and vaping device usage is not being addressed specifically in these interactions. These results demonstrate a need for updated patient screening in regards to tobacco use. Because the majority of e-cigarette users report not knowing that the product contains nicotine, physicians must be made aware of their unknown effects on patient outcomes and the need to screen specifically about e-cigarette usage separately from smoking. Continuing medical education may also help address this gap since many cohorts of practicing physicians were training before the popularity of these types of devices.https://ir.library.louisville.edu/uars/1035/thumbnail.jp

Frequency and Perceived Authenticity of Social Determinants of Health Discussion by Medical Trainees

Introduction Social determinants of health (SDOH)—the conditions in which people live, learn, and work—play a vital, but often neglected role in shaping a community’s health. SDOH influence risk factors for disease and access to healthcare, consequently promoting health inequities among different populations. Examining how providers discuss SDOH with patients can identify opportunities to better integrate social context into care. Methods We analyzed standardized patient (SP) encounters of rising UofL M3 trainees to 1) determine whether SDOH are integrated into healthcare conversations, and 2) investigate what constitutes an authentic conversation to identify how trainees can better express interest in a patient. SP encounters (n=41) were randomly sampled from 139 video recordings of new patient histories. Discussions concerning SDOH categories were coded for content, patient response, and the perceived authenticity of each interaction. Results The most frequently discussed SDOH was employment (80.49% of encounters) while financial security (0%), healthcare access (2.44%), and discrimination (2.44%) were among the least discussed. Trainees appeared more engaged and interested when they empathized with patients, provided reassurance, established personal connections, and displayed a logical/organized flow of thought. Discussion Clinical skills around SDOH could be improved if students were provided more practice incorporating patients’ answers about SDOH into the health management plan. SDOH discussions can be used to get to know the patient holistically and foster strong doctor-patient relationships, both of which are crucial communication/clinical skills assessed by licensing exams. Emphasis on SDOH in medical education can help students advance these skills.https://ir.library.louisville.edu/uars/1039/thumbnail.jp

How medical students screen for HIV with standardized patients establishing care.

How Medical Students Screen for HIV with Standardized Patients Establishing Care AUTHORS Christopher J. Brown, B.S., B.A. Candidate; Emily J Noonan, PhD, MA; Laura A. Weingartner, PhD, MS BACKGROUND Approximately 1.1 million people in the U.S. are living with HIV. The US Preventive Services Task Force (USPSTF) recommends HIV testing for everyone 15-65 years old at least once regardless of sexual activity, with more frequent testing for those considered at risk. METHODS Rising third-year medical students were recorded taking health histories from standardized patients. These recordings were coded for HIV screening, including: risk factors such as unprotected sex, intravenous drug usage, multiple partners, patient/partner HIV status; contextualization by student as to how screening questions related to HIV; and discussion tone (accusatory, informative, or non-judgmental). RESULTS Of the 71 sampled encounters, students identified whether the patient knew their STI status without mentioning HIV status, and 10 students explicitly identified whether the patient knew their HIV status. Similarly, 13 students discussed the STI status of the patient’s partner(s) without mentioning HIV, while only 4 students discussed the HIV status of the patient’s partner(s). In total, only 7 out of 71 students recommended HIV testing to their patient. When discussing patient status, most students (34) were non-judgmental, but one used an accusatory tone while eight were informative. DISCUSSION The results show a lack of explicit HIV discussions and testing recommendations to patients despite USPSTF recommendations that all patients be tested. This study highlights that even when STI status is discussed, many students do not specify HIV status, an important distinction when providing preventive care. Future studies should address how perceived patient risk for HIV and patient identity impact HIV testing recommendations

Prevalence of hormone prescription and education for cis and trans women by medical trainees

PREVALENCE OF HORMONE PRESCRIPTION AND EDUCATION FOR CIS AND TRANS WOMEN BY MEDICAL TRAINEES AUTHORS Madison Meister, BA Candidate; Emily J Noonan, PhD, MA; Laura A. Weingartner, PhD, MS BACKGROUND Hormone replacement therapy is a common healthcare practice for contraception, hormone control, and menopause treatment. Transgender patients may also take hormones to affirm their gender identity, such as feminizing hormones (estrogen), for transgender women. Studying how trainees discuss hormone risks for both cis and trans women can demonstrate if disparities exist and how we may address them to overcome healthcare barriers. METHODS Fifty videos were analyzed of third-year medical students taking patient histories from standardized patients, including 28 cis women and 22 trans women. Students had previously completed LGBTQ clinical skills training, and patients reported taking estrogen purchased online for acne control (cis) or gender-affirming (trans) purposes. Videos were analyzed for the presence and context of hormone health risk discussion, student knowledge, and whether the student agreed to prescribe hormones. RESULTS Of the 90% (n=43) of students who agreed to prescribe hormones, 47% (n=20) prescribed conditionally. Conditions included: pending lab results, desire to research hormones, or checking with attending physicians. A larger proportion of trans women were prescribed hormones (95% or 21/22) compared to cisgender women (79% or 22/28). While similar proportions of students discussed hormone risks between patient groups, students discussed their knowledge or discomfort prescribing hormones more frequently with trans women (27% or n=6/22) than cis women (18% or n=5/28). DISCUSSION We expected students to prescribe combined estrogen-progestin oral contraception to cis women. These data show students more readily prescribed estrogen for gender-affirming purposes, suggesting that LGBTQ clinical skills interventions may help prepare students to provide gender-affirming care

Gender Identity and Pronoun Usage in Standardized Patient Encounters

The standardized documentation clinicians use to record evaluations of a patient are called Subjective, Objective, Assessment, and Plan (SOAP) notes. Consistent pronoun documentation and usage in these notes is especially important for affirming transgender and gender non-conforming patients as this population experiences significant health disparities linked to medical mistrust. A sample of SOAP notes (n=286) was taken from standardized patient encounters at the University of Louisville School of Medicine in 2017 (n=137) and 2018 (n=149). There were five case iterations of the standardized patient based on gender identity. The notes were coded using the software Dedoose for the following themes: pronouns clearly established, consistent pronoun usage, no pronoun usage, and disregard for established pronouns. Pronouns were clearly established in only 27.27% of the notes (n=78/286). Non-cisgender patients were more likely to have pronouns that were clearly established (41% vs 5%). Consistent pronoun usage was most often observed among the notes of cisgender patients. Inconsistent pronoun usage and disregard for established pronouns was observed most often for genderqueer patients (16%, n=14). Complete absence of pronoun use occurred in the notes of trans women (7%, n=3), genderqueer patients (8%, n=7), and cisgender women (3%, n=2) patients. These notes demonstrate a lack of rigor in recording pronouns accurately and consistently for patients, which can be profoundly detrimental to non-cisgender patient care. These discrepancies can be remedied by including training about gender-affirming care and interacting with non-cisgender patients in the clinical skills curriculum

Language Medical Students Use to Comfort Patients Through Difficult Discussions

MERA Abstract Language medical students use to comfort patients through difficult discussions. AUTHORS Zayna Qaissi, BA Candidate; Emily J Noonan, PhD, MA; Laura A. Weingartner, PhD, MS BACKGROUND Comforting communication supports patient satisfaction. Examining how medical students approach potentially sensitive topics can help educators identify strategies that improve the quality of care. The purpose of this study was to examine verbal approaches that student-physicians use to put patients at ease. METHODS Seventy-five medical students were observed in standardized patient encounters. We assessed how students provided comfort by transcribing interview recordings and observing how students addressed the patients’ mental health, sexual history, and a death in the family. All videotaped interviews were rated with a checklist based on the number of important medical aspects for each case. RESULTS Students used different strategies to put patients at ease. Students introduced the sexual history through other topics such as social history (50%) or told the patient directly that the sexual history will be discussed (26%). Many emphasized the importance of the sexual history to the patient’s health and normalized the discussion. Other students (44%) delved into the sexual history abruptly without transitioning. Discussing past mental health issues, students showed empathy by acknowledging health improvement, discussing feelings and concerns, acknowledging stress, or apologizing (31%) to the patient. Empathetic responses to a death in the patient’s family also included apologies (30%) or easing commentary, but most responses were filler words, such as “okay” and “wow” (54%). DISCUSSION This study identified approaches and gaps in the ways students ease patients to promote a smooth flow of information between the patient and the student Focusing on empathetic behaviors is important for enhancing patient care.https://ir.library.louisville.edu/uars/1052/thumbnail.jp

Gender Identity and Pronoun Usage in Standardized Patient Encounters

One of the most common documentation frameworks clinicians use for patient evaluations are Subjective, Objective, Assessment, and Plan, (SOAP) notes. The clinician will usually record medical, family, social, etc. history as “subjective” information. Temperature, blood pressure, lab work, etc. would be considered “objective” information. An evaluation of the patient’s health and possible medical issues would be considered the “assessment,” and their intentions for current and future treatment would be the “plan” within these notes. Trainees often write SOAP notes after completing a standardized patient (SP) encounter—an educational practice used in medical schools to simulate real-world physician-patient interactions in order to develop and assess clinical reasoning skills. A standardized patient is employed to act as a patient, memorizing and reciting previously delineated information provided by medical educators

Prevalence Of Mental Health History Intake By Medical Trainees

BACKGROUND: In the US, 1 in 5 adults experiences a mental illness. Over 9.8 million adults and youths have serious suicidal thoughts, and LGBTQ+ communities experience an even greater burden of mental health disparities. Mental illness is often recognized late by providers, which prevents timely and effective treatment. METHODS: We estimated the frequency and response of healthcare trainees asking about mental health using video-recorded standardized patient interviews conducted by third-year medical students (M3s). Standardized patients are trained to give out specific health history information only when prompted by the student. Students had 30 minutes to complete new patient interviews in a primary care setting. RESULTS: Among a sample of 38 M3s, 60% discussed mental health for an average of 1.3 minutes. Only 26% of these students followed up about a mental health treatment plan. After the mental health disclosure by patients, students responded, I am sorry to hear that (30%), frowned (22%), or offered support and resources to the patient (17%). Not all trainees elicited whether a patient identified as LGBTQ+ or connected patient identity with mental health support. DISCUSSION: We document how mental health histories may not be identified in primary care settings. Many disclosures were also prompted by providers asking about previous hospitalizations rather than mental health specifically. We thus recommend routine mental health history intake for new patients establishing care. Trainees may benefit from comparing interpersonal skills, like empathetic responses between providers and patients, and connecting LGBTQ+ patient identity and terminology to support patients\u27 mental health needs.https://ir.library.louisville.edu/uars/1015/thumbnail.jp

Comparing Medical Student Nonverbal Behavior With Cisgender And Transgender Standardized Patients

BACKGROUND It is essential for medical students to effectively communicate with patients of all gender identities. Nonverbal behaviors such as eye contact and nodding are key communication skills. Evaluating nonverbal behavior is one way to assess the quality of patient care, and examining providers’ behaviors while working with cisgender and transgender patients can identify potential biases linked to patient identity. METHODS To evaluate nonverbal behavior, we analyzed video-recorded training sessions with medical students interviewing standardized patients who identified as cisgender or transgender women. All students identified as cisgender men or cisgender women. Ten nonverbal behaviors were rated from 1-7 using adapted nonverbal communication scales. We also observed whether nonverbal cues were perceived to detract from the encounter. RESULTS Average scores for nonverbal behaviors were similar between students working with cisgender and transgender patients. Nodding frequency showed the largest difference between cisgender (m=5.65) and transgender (m=4.93) patients. When considering student gender identity, men had lower facial expressivity and smiling frequency scores on average but higher scores for unnecessary silence compared to women across encounters. Detracting behaviors that negatively impacted the patient encounters were most likely to be self-touching/unpurposive movements (41%) and unnecessary silences (26%). DISCUSSION The consistency in nonverbal behavior during encounters with cisgender and transgender patients is encouraging. It is possible that LGBTQ health training in medical education contributed to this outcome; however, differences in verbal communication could be more important to health disparities for transgender patients. Additional practice with unpurposive movements and unnecessary silences could improve nonverbal communication skills.https://ir.library.louisville.edu/uars/1056/thumbnail.jp